Exam 2 Cram Sheet Terms

Fundus after birth

at the umbilicus within about 1 hour

No longer palpable

day 10 to 14

Postpartum hemorrhage

1,000ml or any loss within shock signs

Expected heart rate

Bradycardia 50-70bpm for about a week

Fever after 24 hours

38 degrees celcius or higher on two occasions is infection

Rh Immune globulin

Within 72 hours of birth and at 28 weeks

Weight gain for normal BMI

25 to 35 pounds

Added calories

340 for the second trimester and 452 for the third trimester

Folic acid

400-800mcg or 4mg with prior neural tube defects

Gestational diabetes screen

24-48 weeks - 50g one hour

Glucose targets

Fasting under 95, 1 hour under 140, 2 hours under 120

Betamethasone

24-34 weeks for lung maturity

Non-stress test (reactive)

2 accelerations of 15 × 15 in 20 minutes at 32 weeks or more

Biophysical profile

8 to 10 reassuring, 6 equivocal, 4 or less concerning

Fourth stage checks

Every 15 minutes for the first hour

Involution rate

Down about 1cm/one finger breadth per day

Expected blood loss

Up to 500ml vaginal, 1,000ml cesarean

Heavy lochia

Saturated pad in 1 hour

Temp under 38 in the first 24 hours

Attributed to exertion and dehydration

Diuresis

Up to 3,000ml per day for 48 hours

Rubella Vaccine

Before discharge if non-immune, avoid pregnancy for 4 weeks

Weight gain - BMI 30 or above

11-20 pounds

Protein

71 grams daily

Iron and calcium

27mg of iron and 1,000mg of calcium

Confirm

3 hour tests/2 or more abnormal values

Insulin needs

Climb after 20-24 weeks, falls sharply after birth

Magnesium for neuroprotection

Under 32 weeks

Before 32 weeks

10×10

Contraction stress test

Negative is the good result

Epidural blood pressure

Every 2-5 min for the first 15-20 minutes

Rubra

days 1-3; dark red, small clots, fleshy odor (it is concerning if the clots are bigger than a quarter and a pad is soaked in an hour)

Serosa

days 4-10; pinkish brown (any return to bright red is concerning)

Alba

10 days to 6 weeks (any foul odor at any point and/or bright red returning is concerning)

Rule for Lochia

Lochia never goes backward, rubra after serosa means retained fragments or sub involution or the patient is doing too much/straining

4 Ts

Tone, Trauma, Tissue, Thrombin

Tone

Uterine atony (70-80 percent of cases); you will see a boggy uterus, heavy bleeding and often a full bladder; we should first see if its midline and if they recently voided, if so then massage; if it is displaced or has not voided, then empty the bladder first

Trauma

Laceration/Hematoma/Inversion; you will see bleeding with a FIRM fundus or severe pain with a bulging mass; you should notify the provider as this needs inspection and repair

Tissue

Retained fragments; you will see bleeding that persists or returns late, sub involution; you should notify the provider and anticipate an ultrasound and evacuation

Thrombin

Coagulopathy; you will see oozing from the sites, petechiae and no clot forming; you should notify the provider and anticipate labs and product replacement

Firm fundus and still bleeding

This means every answer about massage and uterotonics is wrong; look for laceration or hematoma

Oxytocin

First line uterotonics with no absolute contraindications here

Methylergonovine

A uterotonic you should not use in hypertension (no preeclampsia)

Carboprost

A uterotonic that you should not use in asthma

Misoprostol

A uterotonic that does not require refrigeration

Postpartum blues

Days 3-5 after birth and gone within 2 weeks; they are still able to function; signs may include tearfulness, mood swings, still caring for the baby; this is normal but may require follow up

Postpartum Depression

Any time in the first year and will persist past 2 weeks; she is very impaired; signs are anhedonia, guilt, intrusive thoughts that she knows are wrong; you should screen, refer, and follow up actively

Postpartum Psychosis

Usually within the first 2 weeks and is rapid/fluctuating and is severely impaired; signs include hallucinations or delusions that are often about the infant; this is an emergency and you should never leave her alone with the baby

Endometriosis Findings

Fever 38C or higher after the first 24 hours on two occasions, uterine tenderness, foul lochia, usually day 2 to 3 and is more common after a cesarean

Mastitis Findings

Unilateral, wedge shaped tenderness, fever, flu like aching; keep breastfeeding as the breast must keep draining

Engorgement Findings

Bilateral, firm, warm and painful with no fever

Thromboembolism

Unilateral calf pain, swelling and warmth, with risk highest right after birth. Sudden dyspnea or chest pain is pulmonary embolism until proven otherwise

Placenta Previa

Painless and bright red bleeding; uterus is soft and non-tender (NEVER do a digital vaginal examination)

Placental Abruption

Painful, dark red or concealed bleeding, the uterus is rigid, tender and board like (NEVER delay large bore intravenous access)

Chronic Hypertension

Present before pregnancy or before 20 weeks

Gestational Hypertension

New after 20 weeks, no proteinuria or severe features

Preeclampsia

New after 20 weeks with proteinuria

Preeclampsia with Severe Features

116 or 110 on two readings, a headache that will not ease with medications, visual changes, epigastric or RUQ pain, pulmonary edema, platelets under 100,000, rising creatinine or liver enzymes

Superimposed Preeclampsia

New or worsening proteinuria, or a sudden rise in someone already hypertensive

Eclampsia

A seizure with no other cause; HELLP is hemolysis, elevated liver enzymes and low platelets, and right upper quadrant pain is its classic complaint

Magnesium Sulfate: what is it for

Seizure prophylaxis and fetal neuroprotection (not blood pressure)

Magnesium Toxicity in Order

Flushing and drowsiness → reflexes go → then respirations under 12 → then cardiac

• check reflexes hourly as they are the earliest objective sign

Urine output under 30ml per hour

A separate warning because magnesium is cleared renally and oliguria lets it build up

Antitode for Magnesium Toxicity

Calcium gluconate at the bedside

Epidural: blood pressure falls after placement

Turn her lateral, increase the fluid, oxygen and then notify (most common complication)

Epidural: fetal heart rate falls after placement

Treat the maternal hypotension because that is usually the cause

Epidural: bladder palpable, no urge to void, descent stalled

Catheterize; a full bladder is a soft tissue obstruction

Epidural: headache worse sitting up, better lying flat

Postdural puncture headache → hydration, caffeine and blood patch (inject 15-20ml of the patients blood into the epidural space of the spine to seal CSF leak)

Epidural: she wants to walk

Assess the motor skills and sensation first and never leave them alone

Rubin’s Phases

Taking in is dependent (first 24-48 hours)

Taking hold is independent and question asking (day 2-10 and it is the teachable window)

Letting go reorders relationships

Shock in a young client

Tachycardia and a narrowing pulse pressure comes first and a falling blood pressure is late

Diabetes

1st Trimester: control is about anomalies

3rd Trimester: control is above the size

An insulin need that falls late is a warning about the placenta

Preterm labor drugs

Betamethasone for lungs

Magnesium for the brain

Penicillin for group B strep

Nifedipine to stop contractions